Provider Demographics
NPI:1831528348
Name:PELTON, RYAN (LCSW)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PELTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 FRANKLIN HEALTH COMMONS
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-1946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 FRANKLIN HEALTH COMMONS
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938
Practice Address - Country:US
Practice Address - Phone:207-778-4922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC143291041C0700X
MELC160361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical